<html>
<head>

<style>
body, td {
 font-family: sans-serif;
 font-weight: normal;
 font-size: 9pt;
}
.borderdiv {
 width: 524pt;
 height: 668pt;
 padding: 0;
 border-style: solid;
 border-width: 1px;
 border-color: #000000;
}
.paddingdiv {
 padding: 10pt;
}
.bigtable, .linetable {
 width: 504pt;
}
.linetable {
 margin: 11pt 0 0 0;
}
.mainhead {
 font-weight: bold;
 font-size: 14pt;
 text-align: left;
}
.subhead {
 font-weight: bold;
 font-size: 8pt;
}
.under {
 border-style: solid;
 border-width: 0 0 1px 0;
 border-color: #999999;
}

.ftitletable {
 width: 100%;
 margin: 0 0 0 0;
}
.ftitlecell1 {
 vertical-align: top;
 text-align: left;
 font-size: 14pt;
 font-weight: bold;
}
.ftitlecell2 {
 vertical-align: top;
 text-align: right;
 font-size: 9pt;
 padding-right: 10pt;
}
</style>

<title>{label_webpage_title}</title>
</head>

<body bgcolor='#ffffff'>

<!-- The double div resolves a difference between Firefox and IE in treatment of padding. -->
<div class='borderdiv'><div class='paddingdiv'>

 <table cellspacing='0' cellpadding='0' class='bigtable'>
  <tr>
   <td class='mainhead' valign='top'>
    {header1}
    <span class='subhead'>{label_subhead_clinic}</span>
   </td>
   <td align='right' width='10%' valign='top' nowrap>
    <table border='1' cellpadding='2' cellspacing='0'>
     <tr>
      <td nowrap>{label_clinic_id}</td>
      <td style='width:60pt' nowrap>{fac_facility_npi}</td>
     </tr>
     <tr>
      <td nowrap>{label_clinic_id}</td>
      <td nowrap>{ref_pid}</td>
     </tr>
     <tr>
      <td nowrap>{label_control_no}</td>
      <td nowrap>{ref_id}</td>
     </tr>
     <tr>
      <td nowrap>{label_date}</td>
      <td nowrap>{ref_refer_date}&nbsp;</td>
     </tr>
    </table>
   </td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_name} &nbsp;</td>
   <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
   <td width='1%' nowrap>&nbsp; {label_age} &nbsp;</td>
   <td class='under'>{pt_age}&nbsp;</td>
   <td width='1%' nowrap>&nbsp; {label_gender} &nbsp;</td>
   <td class='under'>{pt_sex}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_address} &nbsp;</td>
   <td class='under'>{pt_street}, {pt_city} {pt_state}&nbsp;</td>
   <td width='1%' nowrap>&nbsp; {label_postal} &nbsp;</td>
   <td class='under'>{pt_postal_code}&nbsp;</td>
   <td width='1%' nowrap>&nbsp; {label_phone} &nbsp;</td>
   <td class='under'>{pt_phone_home}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_ref_reason} &nbsp;</td>
   <td class='under'>{ref_body}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_diagnosis} &nbsp;</td>
   <td class='under'>{ref_refer_diag}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_ref_class} &nbsp;</td>
   <td class='under'>{ref_refer_risk_level}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_dr_name_sig} &nbsp;</td>
   <td class='under'>{ref_refer_from}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_refer_to} &nbsp;</td>
   <td class='under'>{ref_refer_to} / {to_organization}&nbsp;</td>
  </tr>
 </table>

 <hr style='border:0;height:6pt;color:#999999;background-color:#999999;margin:12pt 0 12pt 0;' />

 <table cellspacing='0' cellpadding='0' class='bigtable'>
  <tr>
   <td class='mainhead' valign='top'>
    {header1}
    <span class='subhead'>{label_subhead_patient}</span>
   </td>
   <td align='right' width='10%' nowrap>
    <table border='1' cellpadding='2' cellspacing='0'>
     <tr>
      <td nowrap>{label_clinic_id}</td>
      <td style='width:60pt' nowrap>{fac_facility_npi}</td>
     </tr>
     <tr>
      <td nowrap>{label_clinic_id}</td>
      <td nowrap>{ref_pid}</td>
     </tr>
     <tr>
      <td nowrap>{label_control_no}</td>
      <td nowrap>{ref_id}</td>
     </tr>
     <tr>
      <td nowrap>{label_date}</td>
      <td nowrap>{ref_refer_date}&nbsp;</td>
     </tr>
    </table>
   </td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_name} &nbsp;</td>
   <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
   <td width='1%' nowrap>&nbsp; Age &nbsp;</td>
   <td class='under'>{pt_age}&nbsp;</td>
   <td width='1%' nowrap>&nbsp; {label_gender} &nbsp;</td>
   <td class='under'>{pt_sex}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_clinic} &nbsp;</td>
   <td class='under'>{to_organization}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_address} &nbsp;</td>
   <td class='under'>{to_street}, {to_city} {to_state}&nbsp;</td>
   <td width='1%' nowrap>&nbsp; {label_postal} &nbsp;</td>
   <td class='under'>{to_zip}&nbsp;</td>
   <td width='1%' nowrap>&nbsp; {label_phone} &nbsp;</td>
   <td class='under'>{to_phone}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_ref_reason} &nbsp;</td>
   <td class='under'>{ref_body}&nbsp;</td>
  </tr>
 </table>

 <br />&nbsp;<br />{label_history_summary}:

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_bp} &nbsp;</td>
   <td class='under'>{v_bps}/{v_bpd}&nbsp;</td>
   <td width='1%' nowrap>&nbsp; {label_ht} &nbsp;</td>
   <td class='under'>{v_height}&nbsp;</td>
   <td width='1%' nowrap>&nbsp; {label_wt} &nbsp;</td>
   <td class='under'>{v_weight}&nbsp;</td>
  </tr>
 </table>

 <p>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_ref_name_sig} &nbsp;</td>
   <td class='under'>{ref_refer_from}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_special_name_sig} &nbsp;</td>
   <td class='under'>{ref_refer_to}&nbsp;</td>
  </tr>
 </table>

</div></div>
<br clear='all' /><!-- kludge to fix bizarre Firefox problem with page breaks -->
<p style='page-break-after: always' />
<div class='borderdiv'><div class='paddingdiv'>

 <table cellspacing='0' cellpadding='0' class='bigtable'>
  <tr>
   <td class='mainhead' valign='top'>
    {header2}
    <span class='subhead'>{label_subhead_referred}</span>
   </td>
   <td align='right' width='10%' nowrap>
    <table border='1' cellpadding='2' cellspacing='0'>
     <tr>
      <td nowrap>{label_clinic_id}</td>
      <td style='width:60pt' nowrap>{fac_facility_npi}</td>
     </tr>
     <tr>
      <td nowrap>{label_clinic_id}</td>
      <td nowrap>{ref_pid}</td>
     </tr>
     <tr>
      <td nowrap>{label_control_no}</td>
      <td nowrap>{ref_id}</td>
     </tr>
     <tr>
      <td nowrap>{label_date}</td>
      <td nowrap>{ref_reply_date}&nbsp;</td>
     </tr>
    </table>
   </td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_name} &nbsp;</td>
   <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
   <td width='1%' nowrap>&nbsp; {label_age} &nbsp;</td>
   <td class='under'>{pt_age}&nbsp;</td>
   <td width='1%' nowrap>&nbsp; {label_gender} &nbsp;</td>
   <td class='under'>{pt_sex}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_clinic} &nbsp;</td>
   <td class='under'>{to_organization}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_diagnosis} &nbsp;</td>
   <td class='under'>{ref_reply_init_diag}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_findings} &nbsp;</td>
   <td class='under'>{ref_reply_findings}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_final_diagnosis} &nbsp;</td>
   <td class='under'>{ref_reply_final_diag}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_services_provided} &nbsp;</td>
   <td class='under'>{ref_reply_services}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_recommendations} &nbsp;</td>
   <td class='under'>{ref_reply_recommend}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_scripts_and_referrals} &nbsp;</td>
   <td class='under'>{ref_reply_rx_refer}&nbsp;</td>
  </tr>
 </table>

 <table cellspacing='0' cellpadding='0' class='linetable'>
  <tr>
   <td width='1%' nowrap>{label_special_name_sig} &nbsp;</td>
   <td class='under'>{ref_refer_to}&nbsp;</td>
  </tr>
 </table>

</div></div>

<!-- This should really be in the onload handler but that seems to be unreliable and can crash Firefox 3. -->
<script language='JavaScript'>
window.print();
</script>

</body>
</html>
